DS-15-2003BUILDING
PERMIT APPLICATION
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
_A- ,ANTED
AUG 1,0 2015
FBC 201
Master Permit No.D': (-v; - 2-CQ3
Sub Permit No.
REKILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
i,Q/� �/ CONT�TOR DRAWINGS
JOB ADDRESS: i 'i ! 7 N� io g t �`�
City: Miami Shores Co Miami Dade Zip: 3 3 17-r
Folio/Parcel#: 11- 2131— 03 2"' 01 /0 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):
Address: f'? Mg— WY it
City: /1/14144 911 4e)
Phone#:
State: Zip: 3 3i ?r
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:
(4-144 Ai
Address: 11+ Oa itAU ,e3 ` 1
City: exhiL c• : 3/?'
1
Qualifier Name: :0 1 _ Ph - —11
State Certification or Registrati ''i ,7 _ Certificate of Competence
e#: 3
aS
DESIGNER: Architect/Engineer: Phone
Address: City: State:
Value of Work for this Permit: $ gib 0
•Type of Work:. ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace;
,' -, " , !
Description of Work: a : / )4 014. S ,4) y ,'1
Square/Linear Footage of Work: /ja9-
co
❑ Demolition
Specify color ofcolor 7tt hru tile:
Submittal Fee $ 50 GO Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. 1 understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC
OWNER'S AFFIDAVIT: I certify that all the foregoir yi ion is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning. +�)300,
•
"WARNING TO OWNER: YOUR FAILURE TO REC• D A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING
YOUR NOTICE OF COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement st be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absen
inspection will not be approved and a reinspection fee will be charged.
Signature
V.
OWNER or AGENT
The forego+ng instrument was acknowledged before me this
day of Pr) ) ,20 115 ,by
L,r 1C2 1 , who is personally known to
me or who has produced L. 05'7,4 ?S • 4 6 `/24 L s
identification and who did take an oath.
0°`:• ;°r , AILYN RAVELO
MY COMMISSION 1 FF 214549
EXPIRES: March 29, 2019
Bonded Thru Budget Notary Sentra
Seal:
Signature
of such posted notice, the
The fore
01411
CONTRACTOR
ent was acknowledged before me this
.�. 20 I J , by
S I 1 ' • , who iseersonallynown o
me or who has produced as
identification and who did take an oath.
NOTARY P
S.
Print:
Seal:
rpt""Y°"!4, AILYN RAVELO
,�* MYCOMMISSION1FF214549
EXPIRES: March 29, 2019
lf iK so. Bonded Ttuu Budget Notary Servhes
*************************************************************************************************4, ********
APPROVED BY
(Revised02/24/2014)
Plans Examiner Zoning
Structural Review Clerk
t ioiZ f `'w)-,
41,3
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